Global Journal of Allergy

Dano D1,2, Michel M3, Astier C1,

Couratier P4, Steenbeek N5, SarrP-Y2,
Bonnefoy M3, Boulang M3 and Kanny
G1*
EA 7299, Laboratory of Medical Hydrology
and Climatology, Faculty of Medicine, Lorraine,
University, 54500 Nancy France
2
Genclis, SA, 54500 Vanduvre-ls-Nancy, Nancy,
France
3
Observatoire Rgional de la Sant et des Affaires
Sociales (ORSAS) de Lorraine, 54500 Vanduvrels-Nancy, Nancy, France
4
Association Franaise pour la Prvention des
Allergies, AFPRAL, 75010 Paris, France
5
Prvention des allergies, OASIS, Bruxelles, 1050
Ixelles, Belgium
1

Dates: Received: 24 September, 2015; Accepted:

09 December, 2015; Published: 11 December, 2015
*Corresponding author: Gisele Kanny, EA 7299,
Laboratory of Medical Hydrology and Climatology,
Faculty of Medicine, Lorraine University, 54500
Nancy France, Tel: +33 3 83683640; E-mail:

eertechz

Research Article

Impact of Food Allergies on the

Allergic Persons Travel Decision,
Trip Organization and Stay Abroad
Abstract
This survey evaluated the impact of food allergy on the allergic persons travel decision, trip
organization and stay abroad. Hundred and two persons have participated. Results show that food
allergy prevents 14% of respondents from travelling. Of the 81 travellers, 49% gets anxiety and 46%
fear from food allergy. Difficulties related to food intake at restaurants were expressed by 67% of
travellers. It is shown that allergic travellers adopt preventive behaviours and avoidance attitudes of
allergenic products such as carrying their own food, reading labels, avoiding consumption of local
foods, questioning about food composition. To prevent reaction after accidental ingestion, 69 travellers
carry their emergency kit during travel. However, allergic accidents occurred to 30% of travellers. Food
served in restaurants and homemade foods were the principal causes. This study shows the need to
inform allergic patients about the regulation on the provision of food information to consumers and how
to manage food allergy during travel, the need to establish a policy addressing training of restaurant
staff about food allergy.

www.peertechz.com
Keywords: Food allergy; Survey; Travel

Introduction
IgE-mediated food allergy is a disease characterized by an
immune reaction against an ingested food causing symptoms that can
endanger people at high risk of allergic emergency (anaphylactic shock,
laryngeal angioedema, and severe acute asthma) [1]. Its prevalence is
estimated at 5% in adults and 8% in children [2]. Management of food
allergy relies on developing preventive avoidance strategies of the
allergen involved and on treating symptoms from allergic reactions
when accidental ingestions occur. Research on oral immunotherapy
is being developed to establish food allergens tolerance [3].
At the international level, regulators have issued texts on
mandatory labelling of priority allergens so as to limit the risk
of allergic accidents and to better inform consumers about their
food choices. For example, in Europe, the directive 2007/68/CE
of November 27 2007 amending the annex III bis of the directive
2000/13/CE of the European Parliament and of the Council as regards
to certain food ingredients makes it mandatory to declare on labels 14
food ingredients considered at risk in Europe [4]. Gendel highlighted
the differences between food labelling regulations in different
countries [5]. The number of mandatory allergens to be labelled is
not the same: 14 allergens are concerned in the European Union, 8
in the US and China, 5 in Japan. Eight foods present in most of the
lists are milk, wheat, egg, peanut, fish, crustaceans, soy and tree nut.
Depending on the country, labelling requirements concern either a
food group or a particular food. Therefore, Codex, European Union,
Australia/New Zealand, and Hong Kong specify cereals containing
gluten by a list identifying species (wheat, rye, barley, oats, spelt,

kamut or their hybridized strains) that have to be labelled. In the US

only wheat is included, while Japan and Korea include wheat and
buckwheat; despite the fact that buckwheat does not belong to the
family of cereals. Aboard of airline companies, there are no policies
or regulations that impose labelling of allergens. Airline catering
companies are on an autonomous area that does not abide by the laws
of the country. Allergic accidents have been reported in literature
especially regarding peanut and nut allergies [6-9].
Few studies have investigated the impact of food allergy on the
travel decision, trip organization and stay abroad. Barnett et al have
underlined the difficulties related to travel airlines and restaurants
during travel, particularly for nut allergic persons [10].
This study using online questionnaire aims to evaluate the impact
of food allergy on travel abroad.

Method
Design
To determine the impact of food allergy on the travel decision,
trip organization and stay of an allergic person, an internetbased qualitative survey was conducted through an anonymous
questionnaire posted online via Lime Survey software.

Recruitment
The link to the web-based survey was broadcasted on the site of
the French Association for the Prevention of Allergies (AFPRAL) and
its Belgian counterpart/homologue (OASIS) and their social networks
as well as the Regional Observatory site of Health and Social Affairs
of Lorraine (ORSAS Lorraine, France) for two and a half months. The
questionnaire was written in French and there was no age limitation.
The respondents provided answers voluntarily.

Citation: Dano D, Michel M, Astier C, Couratier P, Steenbeek N, et al. (2015) Impact of Food Allergies on the Allergic Persons Travel Decision, Trip
Organization and Stay Abroad. Glob J Allergy 1(2): 040-043.

040

Dano et al. (2015)

Data generation
The questionnaire included 45 questions targeting the following
themes: population characteristics, level of education and training
to manage food allergy, behaviour regarding their allergy, decision
to travel, organisation for travel and difficulties encountered while
abroad.

Data analysis
Data were collected via lime survey. Questions were treated
separately and content analysis enabled thematic coding. Descriptive
and qualitative analysis of the results were conducted. Symptoms
were graded according to the modified score of Astier et al: 0 is
used for no symptoms, 1 for abdominal pain that resolved without
requiring medical treatment, rhinoconjunctivitis, urticaria fewer than
10 papulas, rash (eczema onset), laryngeal pruritis, 2for one organ
involved, abdominal pain requiring treatment, generalized urticaria,
non-laryngeal angioedema, mild asthma (cough or fall of peak
expiratory flow < 20%), 3 for two organs involved, 4 for three organs
involved or asthma requiring treatment or laryngeal oedema or
hypotension, and 5 for cardiac and respiratory symptoms requiring
hospitalization in intensive care [11,12].

Results
One hundred and two allergic persons (62 women / 40 men) aged
20.2 14.6 years completed the questionnaire. Respondents were
French (93), Belgian (2), Canadian (1), Portuguese (1), Venezuelan
(1), Switzerland (1), Franco-Canadian (1) and Franco-Portuguese
(1). One respondent did not answer this question.
A medical doctor diagnosed food allergy for 97% of the
respondents; allergy was present for more than five years for 64%,
between one and five years for 33%, and less than a year for 4%.
Twenty four percent of respondents were allergic to one allergen
and 76% to more than one. The main allergens responsible for food
allergies were tree nuts (52%), peanuts (43%) and milk (31%) (Figure
1). Forty five percent of respondents had allergies to foods other
than the ones listed in the EU list of mandatory allergen labelling.
According to the score of Astier et al, the severity of previously
reported allergic reactions was in 51% of grade 4, 31% of grade 3, 13%
of grade 2, and in 5% of grade 1.

50%
40%
30%
20%
10%

Impact on decision to travel

Twenty one respondents did not travel, 14 due to their allergy and
6 for personal reasons, one respondent did not answer this question.
Fear is the main reason for not travelling for 5 respondents;
difficulties in managing allergy abroad was mentioned by 4 persons,
language barrier was the reason for one respondent for not travelling,
tedious travel arrangements were responsible for this non-travel for
one respondent.

Travel organisation
Sixty nine of the 81 travellers (85%) carry their emergency kit
during travels.
Allergic persons had information to manage food allergy
during travel from health professionals (13%) and from therapeutic
education sessions (1%), forums for allergic patients (20%) and other
allergic persons (4%). Information about travel was found on food
allergy internet website (49%), travel agency (4%), touristic site (1%)
and dictionary (1%).
Seven percent of travellers said they do not know how to follow
an avoidance diet abroad. Legislation regarding allergens is not
known by 40 travellers (49%). List of mandatory allergen labelling in
the European Union is not known by 38 (47%) and list in the country
visited was not known by 57 (70%) travellers. Translation of the
allergen in the language of the country visited was not known by 18
(22%) of travellers.

Behaviour of allergic persons during travel and stay

52%

45%

43%
31%
22%

19% 18% 18%

15% 14% 14% 13%

10%

0%

Figure 1: Allergens responsible of food allergies in the responders.

041

The 102 respondents have learned about their allergies from

different health professionals: medical doctor specialist in food
allergies (92%), general practitioner (28%), specialized dietician in
the field of food allergies (7%) and nurse specialized in food allergies
(4%). Alternative sources of information were also used: website
for food allergy (36%), internet forum for allergic patient (31%),
patient associations for food allergies (21%), another allergic person
(6%). Therapeutic education sessions were proposed to 19of the 102
respondents and 14 participated to these sessions. Ninety five percent
of respondents have said they read food labels.

Five persons stated that food allergy determines their travel

destinations and their means of transportation.

Population characteristics

60%

Level of education and training to manage food

allergies

Of the 81 travellers, 49% expressed anxiety and 46% experienced

fear.
During travel, 35 persons (43%) informed the transport company
of their food allergy and12 (15%) were served with alternative food
choices taking into account their food allergy. For the 36 persons
(44%) who did not inform the company about their allergy, they
managed their food aboard transportation companies on their own.
Passengers say they take the following measures: 17 carry their
own food; 6 ask for food composition on board, 3 persons did not
do anything and 3 are prudent, 2 travellers do not eat during their

Citation: Dano D, Michel M, Astier C, Couratier P, Steenbeek N, et al. (2015) Impact of Food Allergies on the Allergic Persons Travel Decision, Trip
Organization and Stay Abroad. Glob J Allergy 1(2): 040-043.

Dano et al. (2015)

journey and 1 person takes his own car. Four have their emergency kit
accessible during travel in case of an allergic reaction during travel.
During their stay, seventy five (65%) travellers buy products
already existing in their country and 8% do not check food labelling
for ingredients. Three respondents did not answer this question.
Forty two (52%) travellers buy pre-packaged products they have
not consumed before and 2 without understanding the label on prepackaged products. Thirty six (44%) travellers do not buy products
not consumed before, the following reasons are given: 17 did not
want to take a risk of buying unsafe products, 7 had fear of having an
allergic reaction, 3 could not get access to the exact composition of
the products, 3 did not trust the products, 2 did not understand the
language, 2 had their own food with them, 2 could not find allergen
free products.

Difficulties encountered by food allergic travellers

in restaurants abroad
Fifty four (67%) allergic travellers expressed difficulties related
to their food intake at the restaurants. Difficulties encountered were:
language barrier [16], issues related to the access of the exact food
composition [15], lack of knowledge of staff regarding food allergies
[7], 2 did not answer this question (Table 1).

Allergic accidents during travel and stay

Twenty four travellers have experienced allergic reactions to foods
while travelling in different countries. Half of accidents occurred
outside the European Union (Table 2). All accidents occurred due
to allergens listed in the EU labelling legislation. Two accidents
happened on board of a plane. Causes of accidents were identified
in 13 cases. Nine of the 13 accidents happened in a restaurant, 2 had
allergic reaction due to homemade preparations and 2 respondents
discovered a new food allergy. Allergens responsible for these
accidents were milk, peanut, egg, celery, crustaceans and almonds.

Discussion
Food allergy appears to have an important impact on the travel
decision, trip organization and stay of an allergic person. It prevents
14% of allergic persons from travelling abroad, puts fear in 46% and
anxiety in 49% of those who travel.
Allergic travellers searched for information to manage allergy
during travel and stay. Around 50% of search was made through
internet sites for food allergies, 20% from forums for allergic persons
and only 13% sought information from health professionals. This
Table 1: Difficulties encountered in restaurants.
Difficulties encountered in restaurant

Respondent
(52/54)

Language barrier

16

Access to the exact food composition

15

Lack of staff knowledge about food allergy

lack of seriousness regarding the severity of food allergy

Lack of confidence thatdishes served do not contain allergens

Allergen not considered a priority one in the country visited

Inability to consume local foods in the country visited

Refusal of restaurants to serve because of food allergy

042

Table 2: Country where allergic accidents occurred.

Inside European Union Outside European Union
(number of accidents) (number of accidents)

Transportation company
number of accidents)

Spain (5)

Tunisia (5)

Airline company (2)

Portugal (4)

Brazil (2)

England (2)

Thailand (2)

France (1)

Egypt (1)

Greece (1)

Israel (1)

Germany (1)

Turkey (1)

Polynesia (1)

Vietnam (1)

Martinique (1)

Argentina (1)

Ireland (1)

United states of America (1)

Italy (1)

India (1)
Guatemala (1)
Norway (1)

finding shows the important role of internet regarding easy access

for information and the importance of patients associations and
forums in spreading this information specially when research has
shown the future role of internet and social media in food risk and
benefit communication [13].The use of internet for the diffusion of
the questionnaire select respondents mastering the Internet tool and
constitute a bias of selection. It is likely that these persons are more
inclined to search for information on website. Collaboration between
healthcare professionals specialised in food allergy and webmasters is
important to propose the most relevant information to manage the
travel of a food allergic person. Despite the French law that promotes
implementation of therapeutic education among allergic persons, it
was only proposed to 19% of the respondents. Avoidance diet and
allergen labelling play a key role in the management of food allergies,
7% of respondents declared not knowing how to follow avoidance
diets during travel and around 50% stated not knowing the existence
of allergen labelling legislation.
Allergic travellers adopted preventive behaviours and avoidance
attitudes during travel and stay. Aboard carriers, 7 were vigilant
regarding food composition served on board and 4 carried their
emergency kit in case of an allergic accident. Seventeen decided not
to take risks and carried their own food. During stay, 92% of allergic
travellers read food labelling composition on pre-packaged products
and 44% avoided products they have not consumed before. This
study shows that allergen labelling has an impact on allergic persons
purchasing behaviours during travel and dictated their food choices.
It is important to note that pre-packaged foods are not responsible
of accidents that occurred during travel in our population. Travellers
mentioned difficulties in restaurants due to language barrier, lack
of seriousness regarding severity of food allergy by restaurant staff.
They also had difficulties trusting products served were safe. These
findings join those of Barnett et al., who stated that some allergic
travellers preferred not to travel abroad, go on holidays locally to stay
safe, others reported that food allergies played a key role in deciding
travel destinations. They reported difficulties related to restaurants
and restricted their food intake to plain foods and did not consume
foreign cuisine [10]. The use of a pictogram on food labels would help
allergic travellers to overcome the barrier of language and reading.
Despite adopting preventive behaviours and avoidance attitudes,
30% of travellers experienced allergic accidents abroad. This high

Citation: Dano D, Michel M, Astier C, Couratier P, Steenbeek N, et al. (2015) Impact of Food Allergies on the Allergic Persons Travel Decision, Trip
Organization and Stay Abroad. Glob J Allergy 1(2): 040-043.

Dano et al. (2015)

prevalence of accident is all the more worrying as it concerns a

population of respondents contacted via patient organization
who can be considered as informed consumers. Nine of the 13
allergic accidents were due to food consumed in restaurants; 2 to
preparations of homemade foods and 2 discovered new allergies. Lack
of knowledge of food allergy by catering managers (restaurants, bars,
hotels) affects the safety of allergic persons and underlines the need to
establish a policy in restaurants to train them on food allergy and how
to adopt specific practices to prevent allergic accidents. These findings
are in agreement with the study of Ajala et al that demonstrated
little knowledge of managers and food handlers regarding food
allergy and that there is no policy regarding allergen management in
restaurants [14]. In UK, restaurant staffs knowledge in food allergies
showed considerable misunderstandings of facts about this disease
[15]. Thirty eight percent of restaurant staff believed that drinking
water could dilute the allergen in case of allergic reaction and 21%
considered that removing allergen from a finished meal would make
it safe to consume by an allergic person. As shown by Bailey et al,
training of restaurant staff improves their knowledge in food allergy
and induces changes in practices in the kitchen to serve meals for
allergic consumers [16].
Allergens responsible of accidents were milk, peanut, celery, egg,
crustaceans and almonds and they are all listed in the EU legislation.
These findings highlight the importance of the application of the
EU regulation 1169/2011 stating that when food is consumed in a
place where food is being served, the professional should inform
consumers with free and direct information regarding allergens and
should maintain a written record of the presence of allergens in the
dishes offered.

Conclusion
This survey revealed the significant impact of food allergy on
allergic persons travel decision, trip organization and stay abroad.
Attention is drawn to the lack of knowledge concerning allergen
legislation. The need to provide allergic travellers with adequate
strategies on how to deal with food allergy abroad without fear of
allergic reactions is highlighted. The importance to train restaurant
staff about food allergy is underlined to prevent accidental ingestion.
Controlling the risk of food allergy must be part of an international
debate to harmonize the regulations and allow access of all citizens to
the information needed to manage food allergy in the country visited.
Legislation on air and maritime space must be specified.

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Copyright: 2015 Dano D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

043

Citation: Dano D, Michel M, Astier C, Couratier P, Steenbeek N, et al. (2015) Impact of Food Allergies on the Allergic Persons Travel Decision, Trip
Organization and Stay Abroad. Glob J Allergy 1(2): 040-043.